The King's Fund has been at the forefront of the debate on these issues, tracking A&E performance in our Quarterly monitoring reports.
Here we look at how A&E waiting times have changed over the past few years and explore the impact of different factors, while acknowledging that the causes of the problems in A&E are complex and reflect wider pressures on the NHS and social care.
- What is the A&E standard and how is the NHS performing?
- Has the number of people going to A&E increased?
- Is the pressure on A&E mainly a result of people going to A&E when they should go somewhere else?
- Do more people need to be admitted to a hospital bed from A&E?
- Are delays in discharging patients from hospital having an impact?
- Are A&E pressures due to staff shortages?
What is the A&E standard and how is the NHS performing?
So far in 2015/16 the NHS has struggled to meet the four-hour standard, failing it every month except one (July, when the target was only narrowly met).
The NHS Constitution sets out that a minimum of 95 per cent of patients attending an A&E department in England must be seen, treated and then admitted or discharged in under four hours. This is commonly known as the four-hour standard.
In quarter three of 2015/16 (October to December 2015), the proportion of patients spending longer than four hours in A&E reached its highest level in over a decade. Nine out of ten hospitals with major ‘type 1’ A&E departments (as opposed to single specialty units, walk-in centres and minor injuries units – see box, right, for details) breached the standard.
With the end of 2015/16 approaching it looks almost certain that, for the second year running, the NHS will miss the standard across the year as a whole.
Although overall performance in 2015/16 against the standard has been poor, performance in December 2015 was better (with 87 per cent of patients in ‘type 1’ units waiting less than four hours, and 91 per cent overall) than the same month in December 2014 (for which the respective numbers were 85 per cent and 90 per cent).
Types of unit
- Type 1 A&E department – Major A&E, providing a consultant-led 24 hour service with full resuscitation facilities
- Type 2 A&E department – Single Specialty A&E service (eg ophthalmology, dentistry)
- Type 3 A&E department – Other A&E / Minor Injury Unit / Walk In Centre, treating minor injuries and illnesses
Figure 1 shows A&E waiting time performance over the past decade. From 2005-2010 the proportion of patients spending more than four hours in A&E hovered around 2 per cent – an outcome of the 98 per cent target introduced in 2000 and first met in 2005. However, since 2010, when the coalition government relaxed the target to 95 per cent, the proportion of patients waiting longer than four hours has increased.
Figure 1 also shows how performance against the four-hour standard tends to improve in the summer months. However, while performance recovered in the summer of 2015/16, it still breached the standard.
Has the number of people going to A&E increased?
For many years, the number of people attending A&E remained essentially unchanged at around 14 million a year.
In 2003/4, the number of attendances jumped – by nearly 18 per cent – to 16.5 million. This reflects the decision around this time to incorporate data relating to attendances at walk-in centres and minor injuries units (referred to as ‘type 3 units’ in the figures). These aimed to improve patients’ access to primary care, modernise the NHS to be more responsive to patients’ busy lifestyles, and offer patients more choice (Monitor 2014).
Since then, the overall number of attendances has increased significantly to 22.3 million in 2014/15, a rise of more than 35 per cent over the period. Until 2012/13, attendances in type 2 and 3 units accounted for the vast majority of this increase, with attendances in type 1 units increasing at a much lower rate.
More recently, all types of department have seen the number of attendances increase at a similar rate: between 2013/14 and 2014/15 there were increases of 3 per cent in attendances at type 1 and 3 units and 1 per cent at type 2 units (NHS England).
However, for many hospitals, the number of people who show up at A&E is not the primary problem affecting performance against the four-hour standard. In fact, so far this year, total A&E attendances for the first three quarters are slightly down from the same period last year, yet performance against the standard is worse. The seasonal trend in attendances also supports this: A&E attendances tend to be higher in the summer and lower in the winter. For example, data from the Health and Social Care Information Centre shows that in 2014/15, June and July were the busiest months for attendances with 57,100 and 56,400 per day recorded respectively, while January was the least busy month with 48,800 attendances per day. Yet performance against the four-hour standard tends to be worse in the winter (HSCIC 2016). There are various factors driving this, in particular that during the winter months there is an increase in the proportion of older people attending and in the proportion of people who need to be admitted to a hospital bed as an emergency. Older people and those waiting for admission tend to wait in A&E longer than other people (Blunt 2014), increasing the chances of the four-hour target being breached at this time of the year.
Is the pressure on A&E mainly a result of people going to A&E when they should go somewhere else?
Around 13 per cent of people who attend A&E are discharged without requiring treatment, and a further 35 per cent receive guidance or advice only (HSCIC 2016). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted may well have attended appropriately because they required treatment or assessment that only A&E could provide.
Estimates vary but a survey of 3,000 people in 12 A&E units conducted for the Royal College of Emergency Medicine found that 15 per cent could have been treated in the community; again this is not to say that they all went to A&E 'inappropriately'.
Two of the claims put forward for why people go to A&E unnecessarily are examined below.
Lack of access to GP appointments
It has been suggested that more people are attending A&E because they can’t get appointments with their GP. It is difficult to pin down accurately how many people this might apply to.
However, the latest results from the GP Patient Survey show that 85 per cent of people were able to get an appointment to see or speak to someone at their GP practice, down from 88 per cent in 2011. From the latest figures, of those who couldn’t get an appointment or were offered an inconvenient appointment (11 per cent), around 4 per cent reported going to A&E instead. We know that being able to obtain timely appointments is a key concern for people accessing GP services. However, data from the GP Patient Survey suggests that while there has been a slight reduction in people’s ability to access their GP, there has not been a significant deterioration.
Confusion about the system, including about how to access to out-of-hours care
It has been suggested that removing responsibility for out-of-hours care from GPs (as part of contractual changes in 2004) led to an increase in A&E attendances. However, there is no evidence to support this.
Most people go to A&E during working hours, and these hourly patterns in attendances have remained largely unchanged in recent years. However, people are clearly uncertain about how to access out-of-hours care – results from the GP Patient Survey in July 2015 found that only around 56 per cent of people said they knew who to contact out-of-hours. While this is higher than 2014, it is actually lower than in previous years.
Access to other types of care out of hours (for example, district nursing care) is also important in keeping people out of hospital. We know that the number of district nurses employed by the NHS has decreased by about 36 per cent in the past five years.
The Parliamentary Health Select Committee, the NHS Confederation and many others have expressed concerns that the fragmented provision of urgent and emergency care makes the system confusing for the public. In response to these concerns, the NHS five year forward view commits to doing ‘far better at organising and simplifying the system, with the aim of helping patients to ‘get the right care, at the right time, in the right place’ by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies. To support this, NHS England has been undertaking a review of urgent and emergency care, and has launched 'vanguards' in eight areas of the country to pioneer new approaches to delivering urgent and emergency care services.
Do more people need to be admitted to a hospital bed from A&E?
Evidence suggests that more people are being admitted to hospital from A&E. Compared to 2011/12, in 2014/15 there were an additional 356,000 hospital admissions from A&E departments in England; a growth of 10 per cent over this period.
Admissions from A&E in the first three quarters of 2015/16 are up by almost 1.5 per cent compared to 2014/15. Though a small percentage increase, this is the equivalent of 4,705 additional people a month.
As the number of people admitted from A&E into hospital wards has increased, so have waiting times. This is because people waiting for admission to hospital tend to wait in A&E longer than people who can be treated in A&E or are discharged without treatment (Blunt 2014).
High bed occupancy rates are often associated with worsening A&E performance. In 2014/15, most hospitals were operating at bed occupancy rates above 85 per cent – the level at which the Department of Health and NHS England suggest hospitals will struggle to deal with fluctuations in demand. In the last three winters, the occupancy rate reached 90 per cent (Monitor).
In the third quarter of 2015/16, the number of people who waited in A&E departments for admission to a hospital bed (often described as ‘trolley waits’) for more than four hours after the decision to admit them was 9.5 per cent or more than 98,800 people. Furthermore, the year-to-date figures for 2015/16 show that there were an additional 34,950 people waiting more than four hours from decision to admit from A&E to admission to a hospital bed on a ward compared to 2014/15 (see Figure 4). However, although performance is worse for quarter three 2015/16 overall when compared to the same quarter in 2014/15, figures for December 2015/16 are noticeably better than the same month in 2014/15.
Are delays in discharging patients from hospital having an impact?
The higher number of people waiting to be admitted into a hospital bed from A&E puts pressure on beds in other parts of hospitals. This leads to disruption in the flow of patients through the hospital, including A&E.
Delays in discharging patients (known as ‘delayed transfers of care’) is one of the factors that drives up bed occupancy rates, preventing beds being freed up for those who need to be admitted, and adding to pressures on A&E departments.
The number of delayed transfers of care was relatively stable up until the start of 2014/15 but since then the total number of delayed days has increased by 33 per cent, reaching their highest point since 2008. There has been a particularly steep increase this year, with delayed days rising 12 per cent (equivalent to 16,030 extra delayed days) between April and December 2015.
While the majority of delayed transfers can be attributed to delays within the NHS (62 per cent in 2015/16), the proportion attributable to social care has risen recently (from 26 per cent at the end of 2014/15 to 31 per cent in the third quarter of 2015/16). This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years. In our October 2015 Quarterly monitoring report, 88 per cent of the NHS trust finance directors who took part in our survey told us that they felt funding pressures on local authorities had had a negative impact on the performance of health services in their area.
The figure below shows the total number of delayed days per month. Our discussions with some hospital staff suggest that publicly available figures formally recorded as ‘delayed transfers of care’ do not fully capture the extent of the problem and that many more patients remain in hospital when they are actually well enough to be discharged.
Indeed, the Carter review suggests that, using their sample of hospitals, a more accurate number of delayed patients would be 8,500 per month and not the 5,500 as reported in the official statistics.
However, analysis by Monitor of the reasons behind A&E delays during the winter of 2014/15 suggests that delayed transfers only explained a relatively small increase (rising from around 3 per cent during the winter of 2013/14 to 4 per cent during the same period of 2014/15 – although these figures derive from the publicly available data, which is likely to be an underestimate, as noted above). On this basis, Monitor suggested that hospitals would need to address other factors as well as delayed transfers of care to ease bed occupancy rates. However, delayed transfers have increased sharply since Monitor carried out their analysis, and may now represent a greater proportion of occupied beds.
Are A&E pressures due to staff shortages?
As has been well documented, A&E departments have faced difficulties in recruiting and retaining staff.
Since 2013, Health Education England and the Royal College of Emergency Medicine have been working together to address workforce shortages in emergency medicine, with a particular focus on encouraging more medical students to choose emergency medicine as a career. Information from Health Education England suggests that the actions taken so far have had a positive impact, resulting in 98 per cent of training posts being filled, meaning fewer vacancies and more doctors.
However, staffing issues remain a significant concern. The Royal College of Emergency Medicine reports that, while recruitment into emergency medicine is now high with most first-year emergency medical training posts being occupied, problems with retention mean emergency medicine has the greatest attrition rate of any medical specialty, with almost 50 per cent of year three/four registrars resigning. While Monitor’s recent analysis (2015) concluded that this did not contribute to the longer waits experienced last winter, most A&E departments are working at a very high level of activity, and there is a limit to the workload staff can undertake in the absence of additional staff without it having negative consequences on morale, recruitment and retention, performance and/or patient safety.
A&E waiting times have been increasing over time, with figures for quarter three of this year (October to December 2015) showing that the proportion of people waiting longer than four hours has reached its highest level in over a decade. Furthermore, in 2015/16 the NHS as a whole looks set to miss the standard for the second year running.
The causes of the problems in A&E, and the solutions to address them, are complex. It is often assumed that performance against the four-hour standard has deteriorated due to an increase in attendances, including by some people who could be better treated elsewhere. Although data shows that some people are discharged without treatment, this does not necessarily mean that they have attended A&E unnecessarily. However, NHS England are currently undertaking work to simplify the urgent and emergency care system in response to concerns that current provision is confusing and may be encouraging some people to use A&E as the default option.
Although attendances have increased over time, for many hospitals this is not the primary factor impacting on waiting times. A&E is in constant interaction with other hospital departments (for example, to request diagnostic tests and/or to transfer patients to beds in other parts of the hospital). A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system.
The number of people needing to be admitted from A&E into a hospital bed has increased over time, with rates tending to be highest in the winter. Those waiting for admission tend to wait in A&E longer than other people (Blunt 2014). This is particularly a problem in hospitals when the bed occupancy rate is already high as there is nowhere to put these patients. While there are a number of factors driving bed occupancy rates up, delays in discharging patients out of hospital and back into their homes or another more appropriate setting (such as social care) are a particular concern.
For an analysis of the factors behind A&E delays in 2014/15 specifically, you may also find it helpful to read Monitor’s report A&E delays: why did patients wait longer last winter?
Further resources on urgent and emergency care
- Find out more about our conference on urgent and emergency care
- Watch our animation: An alternative guide to the urgent and emergency care system in England
- See all of our commentary and analysis on urgent and emergency care
- Read our Quarterly monitoring report
- Watch our animation: An alternative guide to the new NHS in England